Alvin Hackel

Professor (Clinical) of Anesthesia and Pediatrics, Emeritus

Anesthesiology, Perioperative and Pain Medicine

Bio

Bio

Dr. Hackel is Professor (Clinical) of Anesthesiology, Perioperative and Pain Medicine, and Pediatrics, Emeritus, at the Stanford School of Medicine. A graduate of Stanford University and its School of Medicine, he was the Chief of the Division of Pediatric Anesthesia at Stanford for 25 years. He is Board Certified in Pediatrics and Anesthesiology.A member of numerous medical societies, Dr. Hackel was the Principal Author of the American Academy of Pediatrics' Guidelines for the Pediatric Perioperative Anesthesia Environment and the Co-Principal author of a parallel document adopted by the American Society of Anesthesiologists and the Society for Pediatric Anesthesia, documents that have led to improvements in the quality of anesthesia care for infants and children at the national and international levels and the development of subspecialty care in the United States. Dr. Hackel has served as a medico-legal with the intent of advancing the high quality of care required for the care of infants and older children.

Other medical fields of interest include the Interfacility Transport of Critically Ill Patients and Regional Neonatal Disaster Preparedness. Dr. Hackel was the principal author of the American Academy of Pediatrics' Guidelines for the Interfacility Transport of Pediatric Patients and the co-developer of a unique infant transport incubator system. Along with his colleagues, he created the Stanford Critical Care Transport and Life Flight Systems. He led the battle to create the California Perinatal Transport System (www.perinatal.org), a state-wide program that transports more than 7,000 critically ill infants annually between community hospitals and regional centers. He was the Director of its Northern Division until last year.

For these endeavors, Dr. Hackel was awarded the Robert M. Smith Award, a life-time achievement award, by the American Academy of Pediatrics Section on Anesthesiology and Pain Medicine.

Publications

All Publications

Abstract

Objective:To develop a strategy to assess the quality of neonatal transport based on change in neonatal condition during transport.Study Design:The Canadian Transport Risk Index of Physiologic Stability (TRIPS) score was optimized for a California (Ca) population using data collected on 21?279 acute neonatal transports, 2007 to 2009, using models predicting (2/3) and validating (1/3) mortality within 7 days of transport. Quality Change Point 10th percentile (QCP10), a benchmark of the greatest deterioration seen in 10% of the transports by top-performing teams, was established.Result:Compared with perinatal variables (0.79), the Ca-TRIPS had a validation receiver operator characteristic area for prediction of death of 0.88 in all infants and 0.86 in infants transported after day 7. The risk of death increased 2.4-fold in infants whose deterioration exceeded the QCP10.Conclusion:We present a practical, benchmarked, risk-adjusted, estimate of the quality of neonatal transport.

Abstract

To evaluate cooling practices and neonatal outcomes in the state of California during 2010 using the California Perinatal Quality Care Collaborative and California Perinatal Transport System databases.Database analysis to determine the perinatal and neonatal demographics and outcomes of neonates cooled in transport or after admission to a cooling center.Of the 223 infants receiving therapeutic hypothermia for hypoxic ischemic encephalopathy (HIE) in California during 2010, 69% were cooled during transport. Despite the frequent use of cooling in transport, cooling center admission temperature was in the target range (33-34?°C) in only 62 (44%). Among cooled infants, gestational age was <35 weeks in 10 (4.5%). For outborn and transported infants, chronologic age at the time of cooling initiation was >6 h in 20 (11%). When initiated at the birth hospital, cooling was initiated at <6 h of age in 131 (92.9%).More than half of the infants cooled in transport do not achieve target temperature by the time of arrival at the cooling center. The use of cooling devices may improve temperature regulation on transport.

Abstract

High-fidelity patient simulation is increasingly recognized as an effective means of team training, acquisition and maintenance of technical and professional skills, and reliable performance assessment; however, finding a cost effective solution to providing such instruction can be difficult. This report describes the rationale, design, and appropriateness of a portable simulation model and example of its successful use at national meetings.The Stanford Simulation Group, in association with several other centers, developed a portable Pediatric Simulation Training and Assessment Program (Pediatric Anesthesia in-Situ Simulation) and presented it at two national meetings. The technical challenges and costs of development are outlined, and a satisfaction survey was conducted at the completion of the program.All respondents (100%) either agreed or strongly agreed that the course was useful, met expectations, was enjoyable, and that the scenarios were realistic.The Portable Simulation Training and Assessment Program (Pediatric Anesthesia in-Situ Simulation) presents innovative educational and financial opportunities to assist in both training and assessment of critical emergency response skills at smaller institutions and allows specialized instruction in an in situ setting.

Abstract

The Pediatric Perioperative Cardiac Arrest (POCA) Registry was formed in 1994 in an attempt to determine the clinical factors and outcomes associated with cardiac arrest in anesthetized children.Institutions that provide anesthesia for children are voluntarily enrolled in the POCA Registry. A representative from each institution provides annual institutional demographic information and submits anonymously a standardized data form for each cardiac arrest (defined as the need for chest compressions or as death) in anesthetized children 18 yr of age or younger. Causes and factors associated with cardiac arrest are analyzed.In the first 4 yr of the POCA Registry, 63 institutions enrolled and submitted 289 cases of cardiac arrest. Of these, 150 arrests were judged to be related to anesthesia. Cardiac arrest related to anesthesia had an incidence of 1.4 +/- 0.45 (mean +/- SD) per 10,000 instances of anesthesia and a mortality rate of 26%. Medication-related (37%) and cardiovascular (32%) causes of cardiac arrest were most common, together accounting for 69% of all arrests. Cardiovascular depression from halothane, alone or in combination with other drugs, was responsible for two thirds of all medication-related arrests. Thirty-three percent of the patients were American Society of Anesthesiologists physical status 1-2; in this group, 64% of arrests were medication-related, compared with 23% in American Society of Anesthesiologists physical status 3-5 patients (P < 0.01). Infants younger than 1 yr of age accounted for 55% of all anesthesia-related arrests. Multivariate analysis demonstrated two predictors of mortality: American Society of Anesthesiologists physical status 3-5 (odds ratio, 12.99; 95% confidence interval, 2.9-57.7), and emergency status (odds ratio, 3. 88; 95% confidence interval, 1.6-9.6).Anesthesia-related cardiac arrest occurred most often in patients younger than 1 yr of age and in patients with severe underlying disease. Patients in the latter group, as well as patients having emergency surgery, were most likely to have a fatal outcome. The identification of medication-related problems as the most frequent cause of anesthesia-related cardiac arrest has important implications for preventive strategies.

Abstract

The American Academy of Pediatrics proposes the following guidelines for the pediatric perioperative anesthesia environment. Essential components are identified that make the perioperative environment satisfactory for the anesthesia care of infants and children. Such an environment promotes the safety and wellbeing of infants and children by reducing the risk for adverse events.

Abstract

The pneumatic tourniquet produces ischemic changes in limbs. The effects of tourniquet release on systemic blood pressure and metabolic parameters were studied in 11 adult patients undergoing total knee replacement under general anesthesia. Mean arterial pressure (MAP) decreased rapidly after the release of the tourniquet, becoming significant at 3 min and remaining significantly depressed up to 15 min post release. Arterial pH, PaO2, PaCO2, lactate acid, and potassium changed significantly after the release, but normalized within 30 min. These results are notably different from a previous study in a similar patient population undergoing knee replacement under epidural anesthesia. Compared to patients under epidural anesthesia, patients receiving general anesthesia with mechanical ventilation are unable to compensate for the metabolic load caused by the tourniquet release, as the latter group are unable to alter their ventilatory rate. In elderly patients with decreased cardio-pulmonary reserve, this may be of clinical importance.

Abstract

To examine the demographics of inpatient anesthesia care for infants and children in a specific region to determine if there were sufficient numbers of procedures to permit credentialing to take place, as a first step in understanding the consequences of implementing credentialing policies based on caseload.Retrospective computerized review of discharge abstracts.All hospitals in northern California.Surgical procedures and date of surgery were linked to create "procedure-days." Each procedure-day counted as one anesthesia case. Annual hospital caseloads (procedure-days) were tabulated for three separate age subgroups under six years of age. The proximity of hospitals with smaller surgical volumes to those with larger volumes was determined. Of the 205 hospitals in the region, 162 had at least one procedure-day for children less than 6 years of age for a total of 14,435 procedure-days (anesthesia cases). For each of three age groups studied--0 to 6 months, 7 to 24 months, and 25 to 72 months--85%, 90%, and 81%, respectively, of hospitals had caseloads of 1 to 50 per year. When procedure days from all three age groups were totalled, 59% of hospitals had less than 20 cases per year and 72% of hospitals had less than 50 cases per year; 86% of hospitals had less than 100 cases per year. Of hospitals with less than 100 cases per year, 75% were within 50 miles of a hospital with more than 100 cases.Performance based credentialing for pediatric anesthesia based on caseload may be problematic for many hospitals due to the distribution of cases: a majority of hospitals care for a few children, and most children are cared for in a few hospitals.

Abstract

Interhospital transport can be hazardous because of rapid changes in a patient's physiologic status and the use of monitoring systems. A retrospective study evaluated the first 204 critically ill adult patients transported from community hospitals to Stanford Medical Center by a special transport team. To relate the risk of transport to severity of illness, a retrospective scoring system was devised. Sixty-one percent (n = 125) of the patients were at high risk for transport. The patients were stabilized at the referring hospital, and invasive monitoring was used as mandated by the patient's condition. The average transport distance was 133 km, and the average duration of transport was 4.38 h. One hundred and five patients (51.5%) were transported by air, and the remaining patients were transported by surface ambulance. All patients survived the transport, and 71.6% were eventually discharged from the hospital. Hospital mortality correlated with the risk-scoring system (p less than .01) and increased five-fold as severity of illness increased. This study demonstrates that, with appropriate hemodynamic stabilization and monitoring, severely ill patients can be transported safely.

Abstract

The primary goal of an interhospital critical care transport program is to provide quality medical care during transit as close as possible to that available in the receiving ICU. Critically ill pediatric patients are transported between hospitals by a variety of transport teams. The skills possessed by physicians, nurses, respiratory therapists, and paramedics overlap. To determine the criteria for selection of the team members for these patients, we reviewed the medical records of 115 pediatric patients transported to this facility in 1978 and 1979. Patients were categorized by diagnosis, severity of illness at the time of transport, and the monitoring and life support required during transport. Our data indicate the medical transport team members should have skills required for pediatric critical care diagnosis and management including endotracheal intubation and assisted ventilation; insertion of peripheral, central venous, and arterial catheters; fluid and electrolyte therapy; antibiotic therapy; cardiovascular monitoring; and pharmacological life support. The team members should be chosen based on the particular skills needed for a transport with a goal of providing the patient care required on a consistent basis.

Abstract

Forty-six neonates with hypoxemia were treated with tolazoline, a pulmonary vasodilator, within the first two days of life. Eight of ten (80%) infants without apparent lung disease responded with a mean increase in PaO2 of 116 torr within one hour of beginning tolazoline infusions. One of the responding infants and two nonresponders died. Thirty-six additional infants with a variety of pulmonary disorders had severe hypoxemia which was refractory to mechanical ventilation. Twenty-one (58%) responded with a mean increase in PaO2 of 130 torr within one hour after beginning tolazoline and 13 (62%) of these survived. Fifteen patients had little or no improvement in PaO2 following tolazoline and only three (20%) of these infants survived. Responders could not be distinguished from nonresponders by clinical or laboratory features prior to therapy with tolazoline. Fourteen infants experienced complications possibly related to tolazoline.